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F FOR &FILE USE: APPLICATION <br /> r _ x 1� W. (For Non-Transferable, Revocable, Suspendable) <br /> �T ENVIRONMENTAL HEALTH PERMIT PUPAP&WELL <br /> L/ <br /> I (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstruct and/or install thework herein described.This application is <br /> made in compliance with Sag JJ- uin CO f�y Ord' ance N2. 1863,and the rule d regulations of the San J quin offal Health District. <br /> Exact Site Address //? Va /jr <br /> _ ------_�--.��- City/Town _ ��!_/ <br /> Owner's Name f <''�' —-- — l( G/ S_P — ----— Phone <br /> Address — -- _ _ City ----- — <br /> Contractor's NameiCense fl � lr Business Phone 1J_ �} 2 <br /> _ j 4 <br /> Contractor's Address _ -- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes L--� - No <br /> TYPE OF WORK (CHECK): NEW WELL C�—'DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER ❑ PUMP INSTALLATION �` PUMP REPAIR C3REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposil Feld_ Cesspool/Seepage Pit 14!!�6) Other <br /> Property Lin Private Domestic Wel! Public Domestic Well <br /> INTENDED.USE TYPE OF WELL <br /> ❑ INDUSTRIAL. ❑ CABLE TOOL Dia, of Well Excavation �Z. % r 4t— <br /> M-60MESTIC/PRIVATE 9�'61RILLEb Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat Q — <br /> ❑ CATHODIC PROTECTION IKOTARY Type of Grout <br /> ❑ DISPOSAL '� ❑ OTHER_ Other Information _ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �i!Jr�(}_ tLJ►r— , /i�/ <br /> I —� — <br /> i <br /> PUMP INSTALLATION: Contractor AIL� 1'tk <br /> Type of Pump— � �!�. -.. J�r ---_ - —_ H.P. . <br /> PUMP REPLACEMENT: ❑ State Work Done_ <br /> PUMP REPAIR: , ❑ State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter — — Approximate — _ I <br /> Describe Material and Procedure Depth <br /> ..C <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ' <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof the work for which this permit <br /> is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> ( Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w It-for a r t pection prior to grouting and a final Inspection. <br /> ,�} <br /> i Signed x _..Title: y� ✓__ %�/ i Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted 6y Date <br /> Additional Comments: <br /> a h <br /> I i II Grout Inspection a"[[[s-e I Fi/n)al Inspection <br /> Inspection BY)"PDate Inspection B )ale <br /> Fee 5 N ❑ ANNUALLY ❑UNIT ❑ PER StTE ❑ EACH ❑ January 1 8 Hnceiyed By Jnnuary 37 ❑ July t &Rrcf)ivC6 By JuEy 91 <br /> t <br /> BILLING REMITTANCE $ RI=MIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED - <br /> !! a — d� - - ---- - — - -- AMOUNT-- <br /> FEE <br /> LESS <br /> r PRORATION _— <br /> PLUS --- -- — <br /> PENALTY <br /> � OTHER <br /> OTHER -- <br /> Received by Dnln Raceipl No. permit N07— Issuance Dwa Mn3I0d DoliVPuTd <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON,CA 95201 ,,� <br />